The Mitrofanoff procedure: 20 years later

Mitrofanoff Appendicovesicostomy in Robotic Paediatric Surgery-A Systematic Review

INTRODUCTION

Proper bladder drainage is crucial. Children with bladder dysfunction may require alternative methods like clean intermittent catheterisation (CIC). However, CIC can be challenging for individuals with impairments. The Mitrofanoff procedure provides a solution by connecting the appendix to the bladder and creating a stoma on the skin, allowing for continent catheterisation. Minimally invasive techniques, including robotics, have been adopted recently. The aim of this study is to review the existing literature on robotic Mitrofanoff procedures.

MATERIALS AND METHODS

A systematic review on paediatric robotic Mitrofanoff procedures on the PubMed, Cochrane, and Scopus databases was conducted according to the PRISMA Statement. Critical appraisals of the included studies were performed with the Newcastle Ottawa Scale.

RESULTS

Six studies were included about the robotic Mitrofanoff procedure. Sex was reported in 50% of the studies. Ages were within the twelve-year age limit, as per the inclusion criteria. The mean operative time was 499.3 (±171.1) min. Four of the six studies reported a length of stay with a median of 6 days (±4; range 1.8-23). The incidence of complications was in line with established benchmarks. Only one study compared the Mitrofanoff procedure to open surgery, finding similar outcomes but longer operating times. Port placement and surgical strategy was described.

CONCLUSIONS

Robotics can offer potential advantages for the Mitrofanoff procedure, despite its application still being in its early stages. This study emphasises the potential safety and efficacy of the robotic approach and promotes the need for further prospective high-quality studies.

Advancing autologous urothelial micrografting and composite tubular grafts for future single-staged urogenital reconstructions

Urogenital reconstructive surgery can be impeded by lack of tissue. Further developments within the discipline of tissue engineering may be part of a solution to improve clinical outcomes. In this study, we aimed to design an accessible and easily assembled tubular graft with autologous tissue, which could be constructed and implanted as a single-staged surgical procedure within the premises of an ordinary operating room. The ultimate goals would be to optimize current treatment-options for long-term urinary diversion. Therefore, we evaluated the optimal composition of a collagen-based scaffold with urothelial micrografts in vitro, and followingly implanted the construct in vivo as a bladder conduit. The scaffold was evaluated in relation to cell regeneration, permeability, and biomechanical properties. After establishing an optimized scaffold in vitro, consisting of high-density collagen with submerged autologous micrografts and reinforced with a mesh and stent, the construct was successfully implanted in an in vivo minipig model. The construct assemblance and surgical implantation proved feasible within the timeframe of a routine surgical intervention, and the animal quickly recovered postoperatively. Three weeks post-implantation, the conduit demonstrated good host-integration with a multilayered luminal urothelium. Our findings have encouraged us to support its use in more extensive preclinical large-animal studies.

Current Surgical Treatment for Neurogenic Lower Urinary Tract Dysfunction in Patients with Chronic Spinal Cord Injury

This study aimed to present a comprehensive literature review of the efforts of a spinal cord injury workgroup in Taiwan regarding urologic surgery for neurogenic lower urinary tract dysfunction (NLUTD) in patients with chronic spinal cord injury (SCI). Surgical procedures should be viewed as a final option for managing patients with SCI who have persistent symptoms and complications that cannot be resolved by other means. Surgeries can be grouped according to their purpose: reducing bladder pressures, reducing urethra resistance, increasing urethra resistance, and urinary diversion. The choice of surgery depends on the type of LUTD based on urodynamic tests. Additionally, cognitive function, hand motility, comorbidities, efficacy of surgery, and related complications should be considered.

Quality of Life in Pediatric Patients with Continent Urinary Diversion-A Single Center Experience

Background and Objectives: The advancement of surgical strategies in various types of urological conditions has resulted in improved functional outcomes, but the issues of patient perception and life quality remain difficult to assess, particularly in pediatric populations. We aimed to critically analyze the outcomes of urinary continent diversion in pediatric patients treated in our institution for various bladder conditions. Materials and Methods: We conducted a cross-sectional study, reviewing the records of patients treated for bladder evacuation problems between 2003 and 2014, and analyzing the data of those with continent urinary diversion. We used two types of questionnaires to assess the impact on life quality: the Qualiveen-30 and the SF-36 Health Survey. Results: The study included one hundred thirty-four patients with bladder conditions, and eight underwent urinary diversion, at a median age of 6.5 years. Seven of them, aged 10-23 years, completed questionnaires, with all seven scoring high on physical functioning scale but low on the social functioning scale. Conclusions: Continent urinary diversion remains the treatment of choice in well selected patients, but the results must be considered both in terms of functional outcomes and the impact on these patients' emotional and mental health.

The Urologist and the Appendix: A Review of Appendiceal Use in Genitourinary Reconstructive Surgery

Recently, genitourinary reconstruction has experienced a renaissance. Over the past several years, there has been an expansion of the literature regarding the use of buccal mucosa for the repair of complex ureteral strictures and other pathologies. The appendix has been an available graft utilized for the repair of ureteral stricture disease and has been infrequently reported since the early 1900s. This review serves to highlight the use of the appendix for reconstruction in urology, particularly focusing on the anatomy and physiology of the appendix, historical use, and current applications, particularly in robotic upper tract reconstruction.

Troubleshooting of failed continence mechanisms in the ileocecal pouch: Operative technique and long-term results of the intussuscepted ileal nipple valve

OBJECTIVES

To provide a detailed step-by-step operative technique, and to report on long-term functional and metabolic outcomes in secondary continence mechanisms in the form of secondary intussuscepted ileal nipple valves in revisional surgery of ileocecal pouches.

METHODS

From May 1997 to May 2015, 18 female and 10 male patients suffering from dysfunctional primary continence mechanisms of their ileocecal pouch underwent revisonal surgery to create a secondary ileal nipple valve at our tertiary referral center. The average follow-up period was 65.4 months.

RESULTS

After surgery, 24 patients were continent by day and night, and four patients showed minor incontinence with the use of a safety pad. The average frequency of clean intermittent catheterization decreased both during the day and at night. The diameter of the catheters used for clean intermittent catheterization increased significantly. No patient showed stomal stenosis, change of stool habits or metabolic situation in the follow-up period. Furthermore, the creation of the secondary ileal nipple valves did not affect the capacity of the reservoir. In the long-term follow up, two patients required the construction of a third continence mechanism, making for an overall success rate of 92% in the study group.

CONCLUSION

To our knowledge, this is the first study of long-term results after the creation of secondary ileal nipple valves. We provide evidence that the creation of a secondary ileal nipple valve is a safe and reliable procedure for continence restoration in ileocecal pouches with excellent functional and metabolic long-term outcomes.

Transvaginal closure of urinary bladder opening and Mitrofanoff technique in a neurologically impaired female with chronic indwelling catheter: a case presentation

BACKGROUND

Chronic catheterization remains the only attractive option in specific circumstances, especially in neurologically impaired patients. Complications produced by the indwelling catheters, like patulous urethra and bladder neck destruction, usually lead to severe incontinence and significant nursing difficulties. Here, we describe a rare case, a urinary bladder opening representing massive and extensive destruction of the urethra and bladder sphincter due to an indwelling catheter.

CASE PRESENTATION

We present a 46-year-old paraplegic woman complaining of recurrent febrile urinary tract infections and severe urinary incontinence. She suffered from persistent malodorous urine and skin breakdowns from constant urine leakage. The vaginal examination revealed extensive destruction of the urethra and a 10 cm opening permitting the urinary bladder wall to prolapse into the vagina. The patient underwent a combined surgical approach; a transvaginal bladder closure with anterior colporrhaphy and a Mitrofanoff procedure to ensure a continent stoma for future clean intermittent self-catheterization (CISC). The patient is compliant with CISC and, remains continent twelve years after surgery.

CONCLUSION

This case demonstrates that in the era of CISC, there are still neurologically impaired females suffering from rare but critical adverse effects of indwelling catheters. The urethra and bladder neck erosion represent a demanding treatment assignment. The Mitrofanoff procedure for continent stoma and the transvaginal closure of urinary bladder opening produced a lifesaving potential treatment.

Outcomes of pregnancy and delivery in women with continent lower urinary tract reconstruction: systematic review of the literature

INTRODUCTION AND HYPOTHESIS

The aim of this systematic review of the literature was to pool all the existing data regarding pregnancy and delivery in women with neurogenic bladder or bladder exstrophy who had undergone previous lower urinary tract reconstruction (LUTR).

METHODS

We conducted a systematic review of the literature from PubMed/MedLine, ClinicalTrials.gov and the Google Scholar database, from 1972 to July 2020. Fifty articles were included, of which 25 contained data that could be pooled (229 women representing 292 pregnancies).

RESULTS

Ninety-eight women had bladder exstrophy (43%), 58 had spinal dysraphism (25%), 14 had spinal cord injury (6%), and 59 presented other pathological conditions. Of these, 138 have had an augmentation cystoplasty (61%), 42 (18%) had a continent cutaneous urinary diversion, and 31 had an artificial urinary sphincter (14%). During their pregnancy, 97 women (33%) experienced at least one febrile urinary tract infection. Thirty-one women (11%) required ureteral stenting or nephrostomy placement for upper urinary tract dilatation. Forty-six pregnancies ended with premature delivery (16%). Delivery mode was by C-section for 108 patients (62%) and vaginal delivery for 104 (36%). Twenty complications were reported during delivery (mainly urological), of which 19 occurred during C-section. Nine women experienced postpartum urinary incontinence (4%); in 5 of then this was due to urinary fistulae secondary to complicated C-section.

CONCLUSIONS

Pregnancy and vaginal delivery are possible for women with LUTR who have no obstetric or medical contraindications, except for some particular cases of bladder exstrophy. However, these high-risk pregnancies and deliveries should be managed by a specialist multidisciplinary team.

Managing intractable incontinence from a Yang-Monti channel in a case of enterocystoplasty with bladder neck closure - Challenges and a modified surgical technique

Incontinence in the Mitrofanoff principle varies between 2% and 40% and is a challenging problem to treat. Incontinence is even more when a Yang-Monti channel is used with simultaneous enterocystoplasty, probably due to ineffective submucosal tunneling owing to the inferior quality of bowel mucosa. Here, we report the management options of such problems along with a novel surgical technique.

Continent Cutaneous Catheterizable Channels in Pediatric Patients: A Decade of Experience with Open and Robotic Approaches in a Single Center

BACKGROUND

To allow patients with bladder and bowel dysfunctions to achieve social continence, continent catheterizable channels (CCCs) are effective alternatives to intermittent self-catheterization and enema.

OBJECTIVE

We aimed to describe our progressive advancement from open to robotic construction of CCCs, reporting outcomes and comparing the two approaches.

DESIGN, SETTING, AND PARTICIPANTS

We retrospectively reviewed electronic medical records of pediatric patients who underwent construction of CCCs between 2008 and 2019. The inclusion criteria were age ≤18 yr, and CCCs with or without bladder augmentation or bladder neck surgery. We compared open versus robotic approaches for demographics, and intra- and postoperative outcomes; operative time was calculated as incision-to-closure time.

SURGICAL PROCEDURE

Channels performed were appendicovesicostomy (APV), Monti with tapered ileum, and antegrade colonic enema (ACE). A Monti channel with tapered ileum was preferred to a spiral Monti or double Monti, as it has more robust blood supply and it was performed only with an open approach.

MEASUREMENTS

The primary outcome was success rate, defined as postoperative stomal continence. Stomal incontinence was defined as the presence of urine leakage noted by caregivers or patients and confirmed by the surgeon. Secondary outcomes were stomal stenosis (supra- and subfascial), incontinence, need for surgical revision, and surgical site infection.

RESULTS AND LIMITATIONS

A total of 69 patients were included in the study, with 35 open and 34 robotic procedures. The robotic approach showed a significant decrease in length of hospital stay (LOS) compared with the open approach. Six primary subfascial revisions were performed in five patients--three Monti, two ACE, and one APV. Continence rates were 91.4% and 91.2% for open and robotic approaches, respectively.

CONCLUSIONS

Robotic surgery for CCCs showed acceptable postoperative functional outcomes and complication rates, which are comparable with those of the traditional open approach. Additionally, due to its minimally invasive nature, it offers advantages such as decreased postoperative pain, LOS, and time to full diet, and better cosmesis.

PATIENT SUMMARY

Robotic surgery for continent catheterizable channels showed acceptable postoperative functional outcomes and complication rates, which are comparable with those of the traditional open approach.

Self-perception, quality of life and ease of catheterization in patients with continent urinary diversion with the mitrofanoff principle

PURPOSE

Continent urinary diversion (CUD) with the Mitrofanoff principle stands as an alternative to urethral catheterization by a route other than the urethra. The aim of the study was to determine self-perception of health-related quality of life (HRQoL), ease of catheterization and global and cosmetic outcomes in patient's dependent on Mitrofanoff catheterization.

MATERIALS AND METHODS

Records of all patients who underwent CUD with the Mitrofanoff principle between 2012 to 2018 were reviewed. Data were collected and analysed retrospectively from medical charts. We assessed HRQoL with the EuroQol EQ-5D-3L questionnaire, cosmetic and global satisfaction with a questionnaire designed by the reconstructive urology board and ease of catheterization with a Likert questionnaire adapted from the Intermittent Catheterization Difficulty Questionnaire (ICDQ) validated in patients reliant on retrograde CIC.

RESULTS

A total of 25 patients requiring CUD with the Mitrofanoff principle between 2012 and 2018 were assessed, the group was composed mainly of: appendiceal conduits 18 patients (72%) and 7 ileal conduits (Yang-Monti) and three of those requiring Casale (Monti Spiral) and 1 a double Monti technique. Median follow-up was 57 months, median age was 30 years. Visual Analogue Scale (VAS) of the EQ-5D-3L reported a Global health score of 86.5%. Fifty nine percent of the patients had no pain or bleeding with catheterizations. Regarding global satisfaction and cosmetic perception 91% were satisfied with their CUD.

CONCLUSIONS

CUD is associated with good HRQoL, global satisfaction, ease and painless catheterization, adequate self-perception of cosmetic outcomes and a low complication rate, remaining a safe and viable option.

Complications in adulthood for patients with paediatric genitourinary reconstruction

BACKGROUND

Caring for adults with prior paediatric genitourinary reconstruction remains a challenge for adult providers. Reconstructions typically have occurred decades before; surgical records are not always available and patients and families may be unable to convey procedures performed. Spina bifida (SB) patients are vulnerable to cognitive decline which may compound these challenges. Changes in patient body habitus and loss of function may contribute to problems with previous reconstructions.

METHODS

This is a non-systematic review of the literature and represents expert opinion where data are non-existent. This review focuses on the evaluation and management of complications arising from genitourinary reconstruction in congenital neurogenic bladder patients.

RESULTS

Common complications experienced by congenital neurogenic bladder patients include recurrent urinary tract infection, incontinence of catheterizable channel and urinary reservoir as well as malignancy as this population ages. Preservation of renal function and prevention of urinary tract infection while optimizing continence are essential guiding principles in the care of these patients. Many of the recommendations, however, are gleaned from available data in the adult spinal cord patient (a more commonly studied population) or the paediatric urologic literature due to limited studies in adult management of such patients.

CONCLUSION

Close follow-up and vigilance is warranted to monitor for infectious, mechanical and malignant complications while optimizing preservation of the upper urinary tracts and patient quality of life.

Urinary diversions: a primer of the surgical techniques and imaging findings

OBJECTIVE

The article attempts to describe the indications, classification, and surgical anatomy of the commonly performed urinary diversion procedures, followed by the imaging protocol and radiological appearances of the normal postoperative anatomy and complications related to these procedures.

CONTENTS

Diversion procedures are used to reroute urine after cystectomy and in patients with refractory neurogenic or outlet obstruction of the urinary bladder. Broadly, these can be classified as continent and incontinent diversions. Patients with urinary diversions frequently undergo radiological investigations for the detection of complications. Commonly, a loopogram or pouchogram is performed few weeks after the surgery to look for leak, whereas CT or MRI is used for long-term follow-up. Postoperative complications can be early (within 30 days of the surgery) or delayed and include leaks, collections, strictures, calculi, parastomal hernia, small bowel obstruction, and oncologic recurrence.

CONCLUSION

A variety of urinary diversion procedures are commonly performed and interpretation of the postsurgical anatomy can be overwhelming for the general radiologist. This article provides a basic understanding of the normal anatomy as well as a thorough discussion on the imaging protocol and radiological appearances of the potential complications associated with these procedures.

Efficacy and security of continent catheterizable channels at short and middle term for adult neurogenic bladder dysfunction

AIMS

The objective of this study was to assess the effectiveness and the complications rate following continent cutaneous channels (CCC) procedures, at short and medium term follow-up (FU).

MATERIALS & METHODS

A continuous retrospective case series (2008-2018): all patients who have undergone a CCC for neurogenic bladder were included in our department. The primary outcome was the effectiveness of CCC defined by the status of catheterizability (by the patient or a care-giver), continence of the tube, and absence of reintervention at 3 and 12 months FU. The secondary outcome was the prevalence of postoperative complications at 3 and 12 months FU.

RESULTS

Fifty-three patients were included during the study period in our department. Median follow up was 3,3 years (1.5-6.1). The overall effectiveness of CCC was 67.9% (n=36/53) at 3 months FU and 45,3% (n=24) at 12 months FU. The global rate of complications was 60.4% (n=32/53) at 3 months, and 73.6% (n=39/73) at 12 months FU. The statistical analysis showed no statistical differences on efficacy and complications in the different subgroups of CCC.

CONCLUSIONS

In the current series, the effectiveness and the complications rates following CCC were comparable across the procedure types.

LEVEL OF EVIDENCE

4.

Robotic-assisted bladder neck procedures in children with neurogenic bladder

PURPOSE

To review the current status of robotic-assisted laparoscopic surgical techniques for bladder neck procedures in children with incontinence secondary to neurogenic bladder.

METHODS

A comprehensive review of the literature on robotic-assisted bladder neck procedures was conducted, with a focus on articles published in the last 25 years. These data were subsequently compared to published series of open bladder neck procedures and published results from robotic-assisted bladder neck reconstruction series completed at our institution.

RESULTS

The principle bladder neck procedures for incontinence in pediatric patients with neurogenic bladder include: Artificial Urinary Sphincter, Bladder Neck Sling, Bladder Neck Closure, and Bladder Neck Reconstruction. Continence rates range from 60 to 100% with a lack of expert consensus on the preferred procedure (or combination of procedures). Robotic-assisted approaches are associated with longer operative times, especially early in the surgical experience, but demonstrate equivalent continence rates with potential benefits including low interoperative blood loss, improved cosmesis, and decreased intra-abdominal adhesion formation.

CONCLUSIONS

Robotic-assisted procedures of the bladder neck are safe, feasible, follow the same steps and principles as those of open surgery and produce equivalent continence rates. Robotic-assisted techniques can be adapted to a variety of bladder neck procedures and safely expanded to selected patients with the previous open abdominal surgery.

The fallow mitrofanoff

BACKGROUND

Treatment of severe congenital dysfunctional bladders often requires bladder drainage to maintain low bladder pressure, thus preserving renal function. Although clean intermittent catheterization is the ideal choice, this can be especially challenging in the younger pediatric population or in children with neurological impairment. Alternatives such as incontinent vesicostomy, long-term suprapubic catheterization, or button cystostomy exist, but these are rarely very long-term options.

OBJECTIVE

The objective of this study is to report the authors' experience with children who underwent a 'fallow' Mitrofanoff, meaning an appendicovesicostomy in which an indwelling catheter was placed for several months or years, allowing for bladder emptying several times a day, until the child was ready for clean intermittent catheterization (CIC).

STUDY DESIGN

All patients who underwent a Mitrofanoff appendicovesicostomy with or without concomitant bladder augmentation, for whom there was a significant delay (≥6 months) between surgery and implementation of CIC, were reviewed. In all these cases, the child showed obvious opposition to CIC. An indwelling catheter was left in place, with a stopper allowing for bladder emptying 5-6 times a day as would happen with CIC. The catheter was changed once a week until CIC was implemented. Complications including febrile urinary tract infections (fUTIs) during the fallow period and complications including leakage or stenosis during the CIC period were noted.

RESULTS

The series includes 10 patients (7 boys and 3 girls), aged a median 41 ± 34 months (range: 23-144) at the time of the appendicovesicostomy (6 posterior urethral valves and 4 non-neurogenic neurogenic bladders). All underwent classic appendicovesicostomies. The delay before full implementation of CIC was a median 29.5 ± 24 months (range: 6-72). During the fallow period, 3 patients presented fUTIs. The catheter was closed, allowing for bladder drainage 4-6 times a day. There were no episodes of leakage from the Mitrofanoff or stomal stenosis during the fallow period or CIC period. Mean follow-up since the appendicovesicostomy is 66 ± 33 months and since initiation of CIC is 26 ± 26 months (range: 4-94).

DISCUSSION

For children who require bladder drainage, an appendicovesicostomy can be performed even if CIC is not initiated immediately and be used as a suprapubic catheter or button cystostomy. When the child is ready, CIC can be initiated without need for further surgery and without risk for the conduit. The limitations of this study include its retrospective nature and the low number of patients.

CONCLUSION

A Mitrofanoff appendicovesicostomy can be performed in a child requiring long-term bladder drainage and in whom classic CIC is not possible, even if CIC is not initiated immediately.

Robotic-Assisted Bladder Neck Procedures for Incontinence in Pediatric Patients

Purpose: To review the current status of bladder neck procedures for incontinence in pediatric patients, focusing on the increasing role of robotic-assisted laparoscopic surgical techniques. Methods: A comprehensive review of the literature on open and robotic-assisted bladder neck procedures was conducted, with a focus on articles published in the last 20 years. This data was subsequently compared with published results from robotic-assisted bladder neck reconstruction series completed at our institution. Results: The principal bladder neck procedures for incontinence in pediatric patients include: Artificial Urinary Sphincter, Bladder Neck Sling, Bladder Neck Closure and Bladder Neck Reconstruction. Continence rates range from 60 to 100% with a lack of expert consensus on the preferred procedure (or combination of procedures). Robotic-assisted approaches are associated with longer operative times, especially early in the surgical experience, but demonstrate equivalent continence rates with potential benefits including: low intraoperative blood loss, improved cosmesis, and decreased intra-abdominal adhesion formation. Conclusions: Robotic-assisted procedures of the bladder neck are safe, feasible, follow the same steps and principles as those of open surgery and produce equivalent continence rates. Robotic-assisted techniques can be adapted to a variety of bladder neck procedures and safely expanded to selected patients with previous open abdominal surgery.

Impact on quality of life and sexual satisfaction of continent cystostomy with enterocystoplasty in an adult neurologic population

AIMS

To evaluate long-term general and urinary quality of life (QOL) and sexual satisfaction in adult neurologic patients undergoing continent cystostomy surgery associated with a bladder enlargement to treat neurogenic lower urinary tract dysfunction.

METHODS

Monocentre, retrospective series of adult neurologic patients who underwent continent cystostomy with bladder enlargement and followed-up in the long-term. We assessed during follow-up, urinary and renal function and patients filled QOL questionnaires on general QOL, sexuality and urinary (short form Qualiveen) disability.

RESULTS

Fifty-three patients were included and followed-up 77 months on average. Rates of patients' satisfaction, stomal and urethral continences were respectively of 98.7% (n = 51), 94.1% (n = 48), and 80.4% (n = 41). Impact of surgery on general QOL and autonomy were strong and positive (respective mean scores of 4.8 and 4.7 on a scale ranging from 1 to 5). Mean overall urinary Qualiveen QOL score was 0.8 (0.09-2.67) indicating a low negative impact of urinary disability on QOL. In patients <45 years, 52.6% (n = 10) reported a moderate to important improvement of their sexuality after surgery. Renal function remained stable during follow-up.

CONCLUSION

In the long-term, continent cystostomy with bladder enlargement provides great satisfaction to almost most patients. It has a strong positive impact on general and specific urinary QOL, patients' autonomy and urinary continence. In young patients a positive impact on sexuality was also noticed. These encouraging data, that need to be confirmed, constitute interesting information to provide to neurologic patients to help them deciding whether they are willing to undergo continent cystostomy surgery.

Serous-lined, stapled pouch wall plication: initial results of a simple and quick novel continence mechanism in troubleshooting secondary to continent cutaneous urinary diversion

OBJECTIVES

To report a novel and straightforward technique of a secondary continent outlet for continent cutaneous urinary diversion (CCUD) reservoirs without the need for further bowel resection, reducing operating time and length of hospitalization.

PATIENTS AND METHODS

From 2015 to 2017, six patients with unreconstructable, incontinent outlets (out of a total pool of 595 patients with CCUD) have undergone the technique described in the present paper at our department. The technique relies on the Mitrofanoff principle, using a stapled full-thickness pouch wall plication, which creates a flap-valve continence mechanism.

RESULTS

All patients enjoyed full continence with ease of clean intermittent catheterization (CIC) in the postoperative period and on follow-up to a mean (range) of 12.4 (7-18) months. No major complications were encountered in any patient and the average capacity of the reservoirs was not compromised by the procedure (540 mL preoperatively vs 500 mL in further follow-up).

CONCLUSION

In revisional surgery for secondary CCUD incontinence, especially if the patient has already lost a significant amount of bowel or has previously undergone radiation therapy, the technique described here represents a safe and effective alternative to restore continence.

Bladder continent catheterizable conduit (the Mitrofanoff procedure): Long-term issues that should not be underestimated

BACKGROUND

Effective bladder emptying by clean intermittent catheterization for children with severe bladder dysfunction is critical for renal preservation and social integration. Use of a continent catheterizable conduit (CCC) as urethral alternative procedure provides effective bladder drainage. However, it brings a substantive maintenance.

METHODS

Retrospective review of the indications and long-term outcomes of 54 patients with a Mitrofanoff procedure in a single center over a 20-year period (1995-2015).

RESULTS

Indications of CCC include 21 neurogenic bladders, 12 patients with epispadias/exstrophy, 13 bladder outlet obstruction, 6 malignancies and 2 cloaca. Median age at surgery was 8.3years (4months-20years). The appendix was used in 76% of cases. Most frequently encountered complication was stomal stenosis (n=17/34, 50%), occurring at median time of 9months (2months-13years). The other complications were: leakage in 9 (26.5%); conduit stricture in 5 (14.7%), angulation of the conduit in 2 (5.8%) and prolapse in one (3%). Operative revision was encountered by 33 (61%) patients, the majority in the first 2years. Median follow-up was 4.3years (3months-16years).

CONCLUSIONS

CCC has a high incidence of complication. It has to be used only when the native urethra is not suitable for catheterization. Carers, patients and families must be prepared to deal with both the complexity of index conditions and the complications of this procedure.

Bladder augmentation in anuric/defunctioned microbladders and a novel antireflux mechanism for Mitrofanoff anastomosis to the ileal patch

BACKGROUND/PURPOSE

Reconstruction of microbladders is a difficult surgical challenge: How can a neobladder be recreated when >90% of the new bladder is augmented patch, and how can a Mitrofanoff conduit be anastomosed when the native bladder is so tiny? This series describes microbladders secondary to anuria and/or diversion that required augmentation. This was done using a de-tubularized ileal segment, and because of the small size of the native bladder, Mitrofanoff anastomosis was performed to the bowel patch (using a novel "Keel Procedure").

METHODS

Our surgical experience in reconstruction of microbladders was reviewed: pre and post augmentation capacity, compliance and maximum detrusor pressure were compared. The success of the Mitrofanoff anti-reflux technique is described. Data are given as median (interquartile range) and compared by Wilcoxon paired rank test.

RESULTS

10 patients, median bladder capacity pre-op 10 (9-20) mls were reconstructed. The follow up time is 2.7years (2.2-4.2). Post-op bladder capacity increased 16-fold to 167 (114-281) mls, P<0.01. Compliance significantly improved from 1.7 (0.3-4.8) to 14.3 (4.1-66.3) mls/cmH₂O, P<0.05. Maximum detrusor over-activity decreased from 27 (7-120) to 12.5 (8-26) cmH₂O, (N.S. P=0.3). Videourodynamics confirmed a leak in 2 patients, leading to incorporation into the technique of a non-absorbable seromuscular suture to provide long-term robustness to the antireflux procedure.

CONCLUSION

Bladder augmentation in microbladders is possible, and a functional Mitrofanoff procedure with a continent anti-reflux procedure can be created using the "Birmingham keel technique" implanting the Mitrofanoff into the augment patch, with 80% success (similar to published results for conventional anastomosis to native bladders).

LEVEL OF EVIDENCE

Level IV.

Continent catheterizable tubes/stomas in adult neuro-urological patients: A systematic review

AIMS

To systematically review all available evidence on the effectiveness and complications of continent cutaneous stoma or tube (CCS/T) to treat bladder-emptying difficulties in adult neuro-urological patients.

METHODS

The search strategy and studies selection were performed on Medline, Embase, and Cochrane using the PICOS method according to the PRISMA statement (CRD42015019212; http://www.crd.york.ac.uk/PROSPERO).

RESULTS

After screening 3,634 abstracts, 11 studies (all retrospective, enrolling 213 patients) were included in a narrative synthesis. Mean follow-up ranged from 21.6 months to 8.7 years (median: 36 months, IQR 28.5-44). At last follow-up, the ability to catheterize rate was ≥84% (except in one study: 58.3%) and the continence rate at stoma was >75%. Data comparing health-related quality-of-life before and after surgery were not available in any study. Overall, 85/213 postoperative events required reoperation: 7 events (7 patients) occurring ≤3 months postoperatively, 22 events (16 patients) >3 months, and 56 events (55 patients) for which the time after surgery was not specified. Sixty additional complications (60 patients) were reported but did not require surgical treatment. Tube stenosis occurred in 4-32% of the cases (median: 14%, IQR 9-24). Complications related to concomitant procedures (augmentation cystoplasty, pouch) included neovesicocutaneous fistulae, bladder stones, and bladder perforations. Risk of bias and confounding was high in all studies.

CONCLUSIONS

CCS/T appears to be an effective treatment option in adult neuro-urological patients unable to perform intermittent self-catheterization through the urethra. However, the complication rate is meaningful and the quality of evidence is low, especially in terms of long-term outcomes including the impact on the quality-of-life.

A multi-institutional study of perioperative and functional outcomes for pediatric robotic-assisted laparoscopic Mitrofanoff appendicovesicostomy

BACKGROUND

Robotic techniques are increasingly being used for reconstructive procedures in the pediatric population.

OBJECTIVE

The present study reported the functional and perioperative outcomes of a multi-institutional cohort of pediatric patients who underwent robotic-assisted laparoscopic Mitrofanoff appendicovesicostomy (RALMA).

STUDY DESIGN

Pediatric patients who underwent RALMA at five different centers were included. Positioning is shown (Summary Figure). Demographics were gathered, and intraoperative parameters included concomitant procedures, detrusor tunnel length, estimated blood loss (EBL) and operative time. Perioperative outcomes included length of hospital stay (LOS), morphine use and 30-day complications. Outcomes were reported in terms of stomal continence and surgical revisions.

RESULTS

Eighty-eight patients with a mean age of 10.4 ± 4.0 years were included in the analysis. Median follow-up was 29.5 months (IQR 11.8-45.0). Bladder augmentation was performed concomitantly in 15 (17%) patients, and bladder neck procedures in 34 (39%). Mean detrusor tunnel length was 3.9 ± 1.0 cm, EBL was 54 ± 70 ml, and operative time was 424 ± 120 min. Postoperatively, mean LOS was 5.2 ± 2.8 days. Patients who underwent concomitant augmentation had higher EBL and operative times (both P < 0.05). At 90 days, complications occurred in 26 patients (29.5%) with six Clavien grade ≥3 (6.8%). During follow-up, 11 (12.5%) patients required appendicovesicostomy revision. Regarding functional outcomes, 75 (85.2%) patients were initially continent. After additional procedures, 81 (92.0%) patients were continent at last follow-up.

DISCUSSION

Compared to previous open series, initial stomal continence rates with RALMA were acceptable, with a minority of patients requiring subsequent procedures to manage complications and achieve continence.

CONCLUSION

RALMA is safe and effective in a pediatric population with regard to perioperative complications and stomal continence.

Does endoscopy of difficult to catheterize channels spare some patients from formal open revision?

INTRODUCTION

Patients with continent catheterizable channels (CCC) may develop difficulty catheterizing postoperatively. In complex cases, endoscopic evaluation with indwelling catheter placement may be indicated, but the risk factors for subsequent formal channel revision are not well defined. The purpose of this study was to determine the risk factors for formal channel revision after attempted endoscopic management of difficulty catheterizing.

MATERIALS AND METHODS

We performed an IRB-approved retrospective review of pediatric (<21 years old) patients undergoing CCC construction at our institution from 1999 to 2014 to identify patients who underwent endoscopy for difficulty catheterizing. Fisher's Exact test was used for categorical data and Mann-Whitney U test for continuous variables to examine the association between endoscopic intervention and subsequent formal revision.

RESULTS

Sixty-three of 434 patients (14.5%) underwent at least one endoscopy for reported difficulty catheterizing their CCC, with 77.8% of these requiring additional intervention during endoscopy (catheter placement, dilation, etc.). Of these, almost half with functioning channels (43.5%, 27/62) were managed successfully with endoscopy without formal revision; six (22.2%) of whom underwent more than one endoscopy. These 27 patients continued to catheterize well at a median follow-up of 3.2 years (interquartile range 2.0-6.0). Patients requiring revision had a median of 1.7 years between CCC creation and first endoscopy, versus 1.6 years in those who were not revised (p = 0.60). There was no statistically significant difference between revised and non-revised channels in terms of patient age at CCC creation, underlying patient diagnosis, status of bladder neck, stomal location, or channel type (p ≥ 0.05) (see Table).

CONCLUSION

Approximately half of our patients did not require a formal channel revision after endoscopic management. We did not identify any specific risk factors for subsequent formal revision of a CCC. We recommend performing at least one endoscopic evaluation for those with difficulty catheterizing prior to proceeding with formal open revision.

Primary Squamous Cell Carcinoma Arising From a Cutaneous Ureterovesical Stoma (Modified Mitrofanoff): Case Report and Review of Literature

Squamous cell carcinoma arising from a urinary stoma is exceedingly rare, and none so far is reported from a cutaneous ureterovesical stoma. Squamous cell carcinoma usually occurs as a late complication of urinary diversion, and we report the first such case in a cutaneous ureterovesical stoma with a review of published literature.

Recent Advances in Urinary Tract Reconstruction for Neuropathic Bladder in Children

Neuropathic bladder usually causes several limitations to patients’ quality of life, including urinary incontinence, recurrent urinary tract infections, and upper urinary tract damage. Its management has significantly changed over the last few years. The aim of our paper is to address some salient features of recent literature dealing with reconstructive procedures in pediatric and adolescent patients with lower urinary tract dysfunction.

Clinical indications for augmentation in children with neurogenic urinary incontinence following bladder outlet procedures: Results of a 14-year observational study

PURPOSE

We report continence, upper tract changes, and augmentation indications and rates in consecutive patients undergoing bladder outlet surgery without augmentation for neurogenic urinary incontinence.

METHODS

From 2000 to 2007, 37 patients underwent bladder neck sling (BNS), and from 2007 to 2013, 45 patients had Leadbetter/Mitchell bladder neck revision plus sling (LMS), all without augmentation. Mitrofanoff channels were created in all cases. Twenty children with persistent outlet insufficiency underwent bladder neck closure (BNC). All patients had pre- and postoperative urodynamic testing (UD).

RESULTS

Mean follow-up was 60 months after BNS, 38 months after LMS, and 29 months after BNC. Continence (dry, no pads) was achieved significantly more often with LMS versus BNS (66% vs. 37%). There were no significant differences between these patients in preoperative UD % capacity, end filling pressure (EFP), or compliance. Those that became dry had a greater % capacity on postoperative UD, but postoperative EFP was similar between dry and wet LMS and BNS patients. BNC resulted in dryness in 65% of patients, with most incontinence occurring from the Mitrofanoff stoma associated with filling pressures > 40 cm. A total of 10 (12%) children had augmentation, seven after BNC. Clinical indications were end filling pressures > 40 cm plus hydronephrosis ≥ grade 3, and/or persistent incontinence. Need for augmentation was not predicted by preoperative urodynamic parameters. Postoperative UD in those who were augmented showed significantly less % capacity and compliance, and significantly greater EFP, than those not augmented.

CONCLUSIONS

Dryness was achieved in only 33% of BNS versus 66% of LMS and BNC patients. Twelve percent of consecutive children undergoing bladder outlet surgery for neurogenic incontinence developed clinical parameters leading to augmentation. These occurred most often after BNC.

Comparison of Complications of Robot-Assisted Laparoscopic and Open Appendicovesicostomy in Children

PURPOSE

Robot-assisted laparoscopic appendicovesicostomy in children has become increasingly popular. However, the literature on this technique mainly consists of small case series with only 1 small comparison to an open cohort. We compared the number of complications and surgical revisions required with open and robotic surgery in children undergoing appendicovesicostomy at our institution.

MATERIALS AND METHODS

We retrospectively reviewed the charts of all patients who underwent appendicovesicostomy by 3 surgeons between July 2002 and September 2013. Acute complications and surgical revisions were recorded and compared between groups with t-tests for continuous variables and Fisher exact test for categorical variables.

RESULTS

A total of 28 open and 39 robotic appendicovesicostomies were included. At a mean followup of 2.7 years there was no difference in number of complications or reoperations (p = 0.788 and p = 0.791, respectively) between groups. Time to first reoperation was shorter in the robotic group. However, there was no significant difference between groups regarding number of patients who underwent reoperation within the first 12 months postoperatively (p = 0.346).

CONCLUSIONS

Comparison of robotic and open appendicovesicostomy revealed no significant difference in the number of acute complications or reoperations between groups. However, the nature and timing of complications differed between groups.

Button vesicostomy: 13 years of experience

INTRODUCTION

Over recent years the button vesicostomy has become an alternative management option in children with poor bladder emptying, when clean intermittent catheterisation (CIC) cannot be initiated for reasons of age, sensation, or urethral anatomy. This study reviews recent experience of this technique and evaluates its use.

METHODS

Retrospective review of patients who had a button vesicostomy to permit bladder drainage between 1998 and 2011.

RESULTS

Thirty children underwent button vesicostomy insertion aged between 4 days and 16 years. Indications were neuropathic bladders (n = 15), congenital hypotonic bladders (n = 6), functional bladder disorders (n = 5), and post-obstruction bladders (n = 4). The median length of use was 11 months; however, 7 patients still have the button in situ. Minor complications (n = 12) included transient leakage, wound infection, and overgranulation. Major complications included 2 UTIs, 1 device failure, and 2 significant leaks, requiring revision of the tract and removal of the button.

CONCLUSION

The button vesicostomy is a suitable and safe technique for use in the short- and medium-term. The procedure has minimal morbidity and therefore is acceptable to families. It has a wide scope, including patients with a neuropathic bladder as an alternative to CIC and where temporary drainage is required until bladder function can recover.

Is it possible to use the rectus abdominis neo-sphincter as a continence mechanism for urinary catheterizable channels? A histologic and histochemical evaluation in an experimental study in rabbits

OBJECTIVE

To evaluate in a rabbit experimental model a mechanism of continence of catheterizable urinary conduits (CUC), focusing on the behavior of intersected rectal muscle fibers in relation to the channel by histological and histochemical analysis, and secondarily to register conduit continence rates from clinical and urodynamic data.

MATERIALS AND METHODS

12 rabbits were submitted to construction of a CUC from two abdominal skin flaps and divided into two groups: 8 with a urinary neo-sphincter created according to Yachia and 4 controls. We registered clinical outcome, urodynamic studies and microscopic analysis of CUC on the surface of the conduit, which was in direct contact with the mechanism of continence. We took muscle samples from the mechanisms of continence and performed histochemical evaluation by enzymatic reactions.

RESULTS

Histological evaluation of the CUC showed no difference between groups. Histology and immunohistochemistry of the muscle fibers showed that areas of necrosis, cell atrophy and motor neuron injury from the first eight weeks recovered by the end of 16th week. Conduit complications occurred in 4 animals (33%). The average detrusor leakage point pressure through the conduit was 90 cm H2O versus 39 cm H2O through the urethra.

CONCLUSION

The mechanism of continence did not promote ischemic stress on the conduit, was able to promote high pressure resistance and showed good recovery of intersected muscle fibers, after an initial slight atrophy, suggesting good durability of the neo-sphincter.

Continent catheterizable vesicostomy in adults: initial experience at a Scandinavian tertiary referral centre

OBJECTIVE

The aim of this study was to present the initial experience of continent catheterizable vesicostomy at a Scandinavian tertiary referral centre.

MATERIAL AND METHODS

Eleven patients, on average 47 years old, with various severe lower urinary tract dysfunctionalities or complete urethral obliteration, underwent reconstruction with a continent catheterizable vesicostomy between 2004 and 2011, with a mean follow-up of 48 months.

RESULTS

For eight patients the first reconstructive attempt was successful. Three patients required more than one operation to become continent and to be able to catheterize easily. Two patients had previously been subjected to bladder neck closure and two had complete urethral obliteration, but no patient in this series had undergone bladder neck closure simultaneous to the vesicostomy procedure.

CONCLUSIONS

For patients who find it difficult to perform self-catheterization via the native urethra, or with an obliteration of the prostatic/membranous/bulbar urethra, construction of a continent catheterizable vesicostomy may be a feasible treatment option. The need for revision is noteworthy. Despite severe difficulties in a few of the patients in the present series, necessitating reoperations, all patients were finally satisfied with the procedure.

A neosphincter for continent urinary catheterizable channels made from rectus abdominal muscle (Yachia principle): preliminary clinical experience in children

PURPOSE

We investigated continence outcomes for patients undergoing primary or redo reconstruction of a urinary catheterizable reservoir involving the Yachia technique of intersecting two rectus abdominis strips over the outlet channel.

MATERIALS AND METHODS

A retrospective evaluation of 22 consecutive patients operated from March 2009 to August 2010 was performed, consisting of 16 primary reconstructions (Macedo catheterizable ileal reservoirs) and 6 rescue cases for leaking stomas. Our data comprised 18 spina bifida patients, 1 sacral agenesis, 1 posterior urethral valves and 1 genitourinary tuberculosis. Mean age at surgery was 8.5 years (3-21 years). We evaluated continence at 3, 6, 12 months, and at the last follow-up based on data from urinary charts.

RESULTS

Mean follow-up was 21.1 months (12-29 months). Overall continence was 100% for the primary cases and 66% for the redos (2/6 failed). Three patients had initial difficulty in performing clean intermittent catheterization but this resolved with time and experience.

CONCLUSION

Using Yachia's technique has improved the continence rate of our catheterizable reservoirs and was partially successful for suprafascial revision of incontinent conduits.

Robot-assisted laparoscopic Mitrofanoff appendicovesicostomy technique and outcomes of extravesical and intravesical approaches

BACKGROUND

With growing experience in pediatric robotic surgery, select centers are now performing robot-assisted, laparoscopic Mitrofanoff appendicovesicostomy (RALMA).

OBJECTIVE

We present our technique and outcomes of RALMA with or without enterocystoplasties and compare stomal outcomes between two different approaches of the appendicovesical anastomosis: an extravesical (EV) anterior bladder approach and an intravesical (IV) posterior bladder approach.

DESIGN, SETTING, AND PARTICIPANTS

Data from 18 children who have undergone RALMA since 2008 were retrospectively reviewed. RALMA was performed by one surgeon in an academic setting.

SURGICAL PROCEDURE

The appendix was anastomosed on the posterior wall of the bladder intravesically when concomitant enterocystoplasty was done. Otherwise, the appendix was anastomosed extravesically on the anterior wall of the bladder.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary outcome measured was the overall continence rate. Secondary outcomes included the overall complication rate and stomal complications.

RESULTS AND LIMITATIONS

The entire cohort included 18 patients (10 IV, 8 EV). The mean overall operative time was 494.1 min. The mean overall length of hospitalization was 5.2 d. There were five immediate, postoperative complications (all Clavien grade 1): three postoperative ilea, one stomal site infection, and one clogged suprapubic catheter. Median follow-up was 24.2 mo. The overall stomal continence rate was 94.4%. One patient from the IV group required dextranomer/hyaluronic acid copolymer for stomal incontinence. Among the eight patients in the EV cohort, there was one stomal complication of stomal stenosis (Clavien grade 1). Among the 10 patients in the IV cohort, there were two stomal complications requiring revisions (both Clavien grade 3): parastomal hernia and stomal stenosis. Limitations of the study include retrospective design, small number of patients, and lack of direct comparison of approaches given the nature of the surgery.

CONCLUSIONS

Our updated outcomes of RALMA with or without enterocystoplasty continue to be encouraging, with a 94.4% continence rate. We believe that anterior EV reimplantation is a feasible option in isolated RALMA.

[Continent cystostomy: monocentric experience]

AIMS

To evaluate the feasibility, the efficiency, the results of continent cystostomy in adult population.

MATERIAL AND METHODS

Retrospective study of patients who underwent a continent cystostomy between 1987 and 2011.

RESULTS

Forty-three patients underwent a continent cystostomy (13 men and 30 women). The mean age at surgery was 53.4±14.6years. The mean BMI was 25kg/m(2). No death in relation with the cystostomy was reported. Thirty-two patients had a neurological pathology (74.4%), 11 a pathology other than neurological (25.6%). A retention bladder was reported for 12 patients (27.9%), 17 (39.5%) were incontinent, and 14 (32.6%) had a mixed symptomatology. All patients had urodynamics and an evaluation of the urinary tract. Nineteen appendicovesicostomy were made, 15 double Monti-procedure, six simple Monti-procedure, three channels were made of an association of ileon and appendix. Seventeen patients underwent an augmentation cystoplasty in combination with the continent catheterizable conduit. The mean follow-up was 47.6±29months. Continence was achieved in 37 patients (86%), two patients underwent a Bricker. Stomal stenosis occurred in eight patients (18.6%), with a median time of 16.1±20.4 months. Leakage occurred after bladder neck closure for two patients (4.6%). Clean intermittent catheterization were performed by 30 patients, catheterization by a care giver for four patients, seven did not use their stomy because of the evolution of their causal pathology, or because of an intercurrent pathology. No difference between the channels (Mitrofanoff versus Monti) was reported.

CONCLUSION

Continent catherizable cystostomy were a feasible method of continent urinary diversion in an adult population. This study demonstrated their feasibility in an adult population and their long-term efficiency with a mean follow-up of 47.6months and 127months for one of them. With a rate of continence upper than 80%, it was an effective technique of urinary diversion associated with intermittent catheterization.

Pediatric laparoscopic and robot-assisted laparoscopic surgery: technical considerations

Laparoscopy has become an effective modality for the treatment of many pediatric urologic conditions that need both extirpative and reconstructive techniques. Laparoscopic procedures for urologic diseases in children, such as pyeloplasty, orchiopexy, nephrectomy, and bladder augmentation, have proven to be safe and effective with outcomes comparable to those of open techniques. Given the steep learning curve and technical difficulty of laparoscopic surgery, robot-assisted laparoscopic surgery (RAS) is increasingly being adopted in pediatric patients worldwide. Anything that can be performed laparoscopically in adults can be extended into pediatric practice with minor technical refinements. We review the role of laparoscopic and RAS in pediatric urology and provide technical considerations necessary to perform minimally invasive surgery successfully.

Clinical experience of the VQZ plasty for catheterizable urinary stomas

OBJECTIVE

To evaluate the effectiveness of VQZ plasty, we analyzed our experience with continent catheterizable urinary stomas using VQZ plasty and V-flap techniques.

PATIENTS AND METHODS

We retrospectively reviewed the records of 25 patients who underwent Mitrofanoff procedures in 2000-2009. All stomas were created in the lower quadrant. There were 10 patients who underwent VQZ plasty and 15 in whom the V-flap technique was used. The stomal complications of these two groups were compared.

RESULTS

Two patients (20%) with VQZ plasty and five (33.3%) with V-flap required surgical revision. Hypertrophic mucosae that excreted mucus and blood periodically were resected in two patients (13.3%) with V-flap. One patient (10%) with VQZ plasty had a surgical site infection. Although the stomal complication rate was lower in patients with VQZ plasty compared to those with V-flap, this difference was not statistically significant (P = 0.4).

CONCLUSIONS

Our results show a tendency towards decreased stomal complications rates in patients with VQZ plasty, suggesting its superiority over the V-flap technique because of good cosmesis. To successfully construct VQZ stomas, surgeons should work to preserve the blood supply of skin flaps and reduce the subcutaneous dead space, and thus reduce the risk of surgical site infection.

Feasibility and early outcomes of robotic-assisted laparoscopic Mitrofanoff appendicovesicostomy in patients with prune belly syndrome

OBJECTIVES

To evaluate the feasibility and report our initial experience with Robotic-Assisted Laparoscopic Mitrofanoff Appendicovesicostomy (RALMA) in patients with prune belly syndrome. The Mitrofanoff appendicovesicostomy procedure uses the appendix to create an easily accessible continent, catheterizable channel into the urinary bladder. Historically, the procedure is performed by an open surgical approach in prune belly patients. We describe our initial experience herein.

MATERIALS AND METHODS

Between October 2008 and February 2010 three patients with prune belly syndrome underwent RALMA. The appendicovesicostomy anastomosis was performed on the anterior bladder wall and the stoma was brought to the umbilical site or right lower quadrant. At least 4 cm of detrusor backing was ensured. The appendicovesicostomy stent was left in place for 4 weeks postoperatively before initiation of catheterization.

RESULTS

Mean age at surgery was 9.7 years (range 5-14 years). Blood loss volume was 20 mL in each case. Overall mean operative time was 352 min (range 319-402 min). There were no intraoperative complications and no open conversions. There was one postoperative complication in the form of wound infection. All patients are catheterizing their stomas and are continent at an average follow-up of 14.7 months (range 5-21 months).

CONCLUSION

In our initial experience, RALMA is a feasible option with encouraging early experience for creating a continent catheterizable channel into the urinary bladder in patients with prune belly syndrome.

Use of cutaneous flap for continent cystostomy (daoud technique)

PURPOSE

We present the results of a new technique using a pedicled cutaneous flap for continent cystostomy.

MATERIALS AND METHODS

A total of 15 boys and 8 girls (mean +/- SD age 13.4 +/- 6.4 years) underwent continent cystostomy for neurogenic bladder (20), bladder exstrophy (2) and sequelae of hypospadias (1) between 1999 and 2008. In this procedure a rectangular pedicled flap is surgically elevated from a hairless area on the abdomen. The flap is tubularized and passed through the anterior abdominal wall directly into the bladder. A submucosal detrusor incision is made to expose the bladder mucosa, and the distal part of the flap is anastomosed to the bladder mucosa in a circular manner. The tube is positioned along the incised detrusor, which is closed over. Viability of the flap, self-catheterization management and continence status are then evaluated.

RESULTS

Mean +/- SD followup was 4.5 +/- 3.1 years. There was 1 case of distal necrosis of the flap, which required a secondary surgery using the Mitrofanoff technique. The 22 remaining flaps were initially viable, although 2 patients were eventually lost to followup and 3 subsequently presented with false-passage incidents requiring a few days of calibration using a balloon catheter. Dryness was achieved immediately in 73% of the cases. After adding a complementary bulking agent the dryness rate reached 77%.

CONCLUSIONS

We present a novel approach to continent cystostomy that is safe and easy to perform. This technique is a less invasive and more efficient alternative to other commonly used approaches.